The Real Obamacare Story: States’ rights and wrongful exclusion

On October 1, 2013, two key provisions of the US Affordable Care Act (aka Obamacare) designed to extend health insurance to the close to 41 million uninsured Americans took effect. The one that garnered all the political and media attention was the individual mandate provision, requiring individuals with no insurance to buy private health insurance policies. The law allows states to set up their own online health insurance exchanges to offer these policies, enter a state-federal partnership, or default into the federally created exchange. Twenty-seven states, in part to protest Obamacare, decided not to set up their own exchanges and left it to the feds. As everyone exposed to US media knows by now, the federal exchange website messed up big time, temporarily precluding people from being able to sign up in October and parts of November. The glitches have pretty well been resolved and people are enrolling.

Clockwise from left: women’s healthcare treatment; President Obama signing the ACA bill; medical services; US Supreme Court justices. All photos labeled for reuse and provided by Wikimedia commons or Flickr.

The other key provision was the extension of the government-funded Medicaid program to adults whose incomes fell below 138 percent of the US federal poverty income threshold. This is a big deal. In 2011, about 40 percent of all uninsured adults under the age of 65 had incomes below 138 percent of the poverty line (US$15,847 for an individual or US $24,9724 for a family of three in 2011). Since the 1965 passage of Medicaid (the US health insurance program for the poor and disabled), states have administered the program and have some policy discretion over coverage and partial funding responsibilities. As a result, the program never covered most poor adults. Obamacare was finally about to change that.

However, a June 2012 Supreme Court ruling allowed states to opt out of the Medicaid extension without having to also opt out of their on-going Medicaid programs. In response, 25 states have decided to opt out of the Medicaid extension. In a background paper I prepared for a forthcoming UN Women’s Progress of the World’s Women Report (2011–2012 report linked here), I estimate that about 8.5 million otherwise eligible adults will now not be covered under Medicaid because of where they happen to live. That’s one out of every five uninsured persons between the ages of 18 – 64 in the US. Unlike the website fiasco, this exclusion is deliberate and not temporary. Yet, there has been very little press coverage or political outcry.

The feds will pay for 100 percent of the Medicaid extension costs for three years and then phase down to 90 percent coverage by 2020. Adopting this program should have been a no-brainer. Yet the 25 states led by Republican governors actively chose not to do so. Most of these states are in the South and Midwest and have relatively high percentages of black adults. Further, because women are (on average) poorer than men, the single group most hurt by this display of states’ rights is black women. In opting out, these states combined to deny 35 percent of all uninsured black women government-sponsored health insurance (compared to 23 percent of uninsured white women, 24 percent of uninsured Latinas, and 10 percent of uninsured Asian women). Making things even worse, most of this group excluded from the Medicaid expansion is also excluded from Obamacare subsidies for private insurance.

Enabling states’ rights in antipoverty programs, an enduring feature of the US political system, has historically reproduced enduring racist and misogynist wrongs. Obamacare, with the help of the Supreme Court, unfortunately provides no exception.